Impact of site-specific metastases on survival outcomes in pancreatic adenocarcinoma (PDAC) patients: A national analysis

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Background: PDAC is the third most fatal cancer, where most patients present with metastases at diagnosis. Previous studies, including a retrospective analysis from our single-center experience, suggests survival rates are significantly higher for those with lung-only metastases (mets) when compared to liver metastasis or other sites of metastases (liver+other). The objective of this analysis is to explore this difference based on sites and metastasis and the impact of chemotherapy from a national cohort. Methods: We identified PDAC patients (>18years) from with metastases to either 1) lung-only; 2) liver+other sites in the National Cancer Database diagnosed between 2010 and 2015.We analyzed patient characteristics, demographics, type of chemotherapy, and survival outcomes. Kaplan Meir survival curves were generated, and Cox proportional hazard models adjusted for age and sex were fit to evaluate associations between met site and survival. Survival was calculated from time of diagnosis to death and compared across mets site, receipt of chemotherapy, and treatment and type (single versus multi-agent). Results: 15359 PDAC patients were included in the analysis [51.6% male 48.4% female, mean age 69 years] of which 4512 (29.4%) patients had lung only mets and 10847 (70.6%) had liver + other mets. Median survival was 5.72 and 2.37 months for lung only vs. liver+other mets, respectively (log rank p<0.001). From a subset population of 8440 patients who received chemotherapy, median survival of 9.4 and 4.9 months for lung only and liver+other mets was observed, respectively [Table]. Median OS for single agent chemotherapy was 4.4 months (n=2637), with patients with lung only mets having a median OS of 7.1 months and those with liver+other mets having a median OS of 3.6 months. Median OS for patients treated with multi-agent chemotherapy (n=5380) was 7.4 months, with lung only met patients having a median OS of 11.6 months and those with liver+other mets having a median OS of 6.1 months. Hazard ratios (HR) and 95% confidence intervals (CI) are displayed in the table. Conclusions: In a national cohort, patients with metastatic PDAC and lung-only metastasis had improved survival when compared with liver +other metastasis. Further contemporary research is needed to understand the underlying biology that dictates the survival difference between lung metastasis vs other sites of metastatic disease in pancreatic cancer.[Table: see text]

Management of Difficult Choledocholithiasis

Over 30% of all endoscopic retrograde cholangiography procedures in the US are associated with biliary stone extraction, and over 10-15% of these cases are noted to be complex or difficult. The aim of this review is to define the characteristics of difficult common bile duct stones and provide an algorithmic therapeutic approach to these difficult cases. We describe additional special clinical circumstances in which difficult biliary stones are identified and provide additional management strategies to aid endoscopic stone extraction efforts.

Characteristics of Patients Undergoing Endoscopic Retrograde Cholangiopancreatography for Sphincter of Oddi Disorders

The concept that sphincter of Oddi dysfunction (SOD) can cause attacks of biliary-type pain in postcholecystectomy patients and those with unexplained recurrent acute pancreatitis, and that endoscopic sphincterotomy can ameliorate symptoms, remains unproven. The Evaluating Predictors and Interventions in Sphincter of Oddi Dysfunction (EPISOD) study of patients without objective evidence for biliary obstruction showed no difference in outcomes between those who underwent sphincterotomy or sham treatment.¹ To date, there have been no studies examining the characteristics of patients who still are being offered endoscopic retrograde cholangiopancreatography (ERCP) for SOD since the EPISOD publication, although the absolute number appears to have declined.².

Predicting pancreatic ductal adenocarcinoma using artificial intelligence analysis of pre-diagnostic computed tomography images

BACKGROUND

Early stage diagnosis of Pancreatic Ductal Adenocarcinoma (PDAC) is challenging due to the lack of specific diagnostic biomarkers. However, stratifying individuals at high risk of PDAC, followed by monitoring their health conditions on regular basis, has the potential to allow diagnosis at early stages.

OBJECTIVE

To stratify high risk individuals for PDAC by identifying predictive features in pre-diagnostic abdominal Computed Tomography (CT) scans.

METHODS

A set of CT features, potentially predictive of PDAC, was identified in the analysis of 4000 raw radiomic parameters extracted from pancreases in pre-diagnostic scans. The naïve Bayes classifier was then developed for automatic classification of CT scans of the pancreas with high risk for PDAC. A set of 108 retrospective CT scans (36 scans from each healthy control, pre-diagnostic, and diagnostic group) from 72 subjects was used for the study. Model development was performed on 66 multiphase CT scans, whereas external validation was performed on 42 venous-phase CT scans.

RESULTS

The system achieved an average classification accuracy of 86% on the external dataset.

CONCLUSIONS

Radiomic analysis of abdominal CT scans can unveil, quantify, and interpret micro-level changes in the pre-diagnostic pancreas and can efficiently assist in the stratification of high risk individuals for PDAC.

Incidence of Pancreatic Cancer by Age and Sex in the US, 2000-2018

This study uses data from the Surveillance Epidemiology and End Results database to perform an age- and sex-specific time trend analysis of pancreatic cancer incidence rates in US adults.

Discovery of serum biomarkers for diagnosis of tuberculosis by NMR metabolomics including cross-validation with a second cohort

Background

Tuberculosis (TB) is a disease with worldwide presence and a major cause of death in several developing countries. Current diagnostic methodologies often lack specificity and sensitivity, whereas a long time is needed to obtain a conclusive result.

Methods

In an effort to develop better diagnostic methods, this study aimed at the discovery of a biomarker signature for TB diagnosis using a Nuclear Magnetic Resonance based metabolomics approach. In this study, we acquired ¹H NMR spectra of blood serum samples of groups of healthy subjects, individuals with latent TB and of patients with pulmonary and extra-pulmonary TB. The resulting data were treated with uni- and multivariate statistical analysis.

Results

Six metabolites (inosine, hypoxanthine, mannose, asparagine, aspartate and glutamate) were validated by an independent cohort, all of them related with metabolic processes described as associated with TB infection.

Conclusion

The findings of the study are according with the WHO Target Product Profile recommendations for a triage test to rule-out active TB.

Fluoroscopy-guided shaped endobiliary biopsy at endoscopic retrograde cholangiography can accurately diagnose biliary neoplasia: Results from a large cohort

Background and study aims  The sensitivity of using standard endobiliary forceps biopsy to diagnose neoplastic biliary lesions remains low. We have developed a unique biopsy approach, termed fluoroscopy-guided, shaped endobiliary biopsy (FSEB), in which the biopsy forceps are modified to improve diagnostic yield. In this study, we evaluate the diagnostic characteristics of FSEB for endobiliary lesions at endoscopic retrograde cholangiography (ERC). Patients and methods  Consecutive patients undergoing FSEB between 1/2001 and 12/2014 were retrospectively enrolled. The identification of neoplastic lesions with FSEB, was the primary endpoint. The gold standard of neoplasia was histopathology, cytology or surgical histopathology. The benign cases were followed up for one year. Results  A total of 204 patients undergoing 250 biopsy sessions by FSEB were analyzed. Per-patient analysis was performed and FSEB showed 81.1 % sensitivity and 88.2 % accuracy. FSEB detection of proximal biliary lesions was more sensitive (91.1 % vs 73.2 %, P  < 0.01) and accurate (94.9 % vs 82.2 %, P  < 0.01) compared to distal lesions. No complications from FSEB were reported. Conclusions  FSEB shows high accuracy for diagnosis of neoplasia in biliary strictures, especially for proximal lesions. Future prospective randomized controlled studies are merited to further validate the role of FSEB as the first-line sampling tool for evaluation of biliary neoplasm.

Endoscopic Suturing for the Prevention and Treatment of Complications Associated with Endoscopic Mucosal Resection of Large Duodenal Adenomas

Background/Aims

Endoscopic mucosal resection (EMR) is the primary treatment for duodenal adenomas; however, it is associated with a high risk of perforation and bleeding, especially with larger lesions. The goal of this study was to demonstrate the feasibility and safety of endoscopic suturing (ES) for the closure of mucosal defects after duodenal EMR.

Methods

Consecutive adult patients who underwent ES of large mucosal defects after EMR of large (>2 cm) duodenal adenomas were retrospectively enrolled. The OverStitch ES system was employed for closing mucosal defects after EMR. Clinical outcomes and complications, including delayed bleeding and perforation, were documented.

Results

During the study period, ES of mucosal defects was performed in seven patients in eight sessions (six for prophylaxis and two for the treatment of perforation). All ES sessions were technically successful. No early or delayed post-EMR bleeding was recorded. In addition, no clinically obvious duodenal stricture or recurrence was encountered on endoscopic follow-up evaluation, and no patients required subsequent surgical intervention.

Conclusions

ES for the prevention and treatment of duodenal perforation after EMR is technically feasible, safe, and effective. ES should be considered an option for preventing or treating perforations associated with EMR of large duodenal adenomas.

Active and prospective latent tuberculosis are associated with different metabolomic profiles: clinical potential for the identification of rapid and non-invasive biomarkers

Although 23% of world population is infected with Mycobacterium tuberculosis (M. tb), only 5-10% manifest the disease. Individuals surely exposed to M. tb that remain asymptomatic are considered potential latent TB (LTB) cases. Such asymptomatic M. tb.-exposed individuals represent a reservoir for active TB cases. Although accurate discrimination and early treatment of patients with active TB and asymptomatic M. tb.-exposed individuals are necessary to control TB, identifying those individuals at risk of developing active TB still remains a tremendous clinical challenge. This study aimed to characterize the differences in the serum metabolic profile specifically associated to active TB infected individuals or to asymptomatic M. tb.-exposed population. Interestingly, significant changes in a specific set of metabolites were shared when comparing either asymptomatic house-hold contacts of active TB patients (HHC-TB) or active TB patients (A-TB) to clinically healthy controls (HC). Furthermore, this analysis revealed statistically significant lower serum levels of aminoacids such as alanine, lysine, glutamate and glutamine, and citrate and choline in patients with A-TB, when compared to HHC-TB. The predictive ability of these metabolic changes was also evaluated. Although further validation in independent cohorts and comparison with other pulmonary infectious diseases will be necessary to assess the clinical potential, this analysis enabled the discrimination between HHC-TB and A-TB patients with an AUC value of 0.904 (confidence interval 0.81-1.00, p-value < 0.0001). Overall, the strategy described in this work could provide a sensitive, specific, and minimally invasive method that could eventually be translated into a clinical tool for TB control.

Is sore throat an underreported and under-estimated quality indicator for endoscopic procedures? Results from a large prospective cohort

Background and study aims  Patients often develop sore throat after upper endoscopy procedures but there data are very limited on the magnitude of the problem. The aim of this study was to evaluate and identify independent risk factors of sore throat in patients undergoing endoscopy. Patients and methods  Data were collected prospectively on consecutive outpatient endoscopy procedures performed at Cedars-Sinai Medical Center from October 2018 to February 2019. Procedure nurses collected pre-procedure, intra-procedure, and immediate post-procedure surveys including evaluation of sore throat (pain scale from 1 - 10). Significant univariate variables ( P  < 0.05) were entered into a multivariate logistic regression model. Results  Data were collected on 715 patients. Four hundred seventy-two patients (mean age = 61 years, females = 53 %) were included in the analysis and 85 patients (18 %) experienced post-procedure sore throat. On univariate analysis, female gender, oral endoscopic ultrasound (EUS), oral double balloon enteroscopy (DBE), fellow involvement, throat suctioning, general anesthesia, oral airway, and prolonged procedure (> 30 minutes) were risk factors for sore throat (all P  < 0.05). On the multivariate analysis, independent risk-factors for post-procedure sore throat were oral DBE (odds ratio [OR] 5.2), oral airway (OR 4.8), general anesthesia (OR 2.7), fellow involvement (OR 2.5), oral EUS (OR 2.4), and female gender (OR 2.0). Conclusions  Contrary to popular belief, our study found that post-procedural sore throat is more common (18 %) than previously reported. Two types of endoscopic procedures, two anesthesia maneuvers, female gender, and fellow involvement were all independent risk factors. This is of particular concern for interventionalists who perform EUS and oral DBE as these patients are at higher risk for sore throat.

Multiparametric Mapping Magnetic Resonance Imaging of Pancreatic Disease

Background

Current magnetic resonance imaging (MRI) of pancreatic disease is qualitative in nature. Quantitative imaging offers several advantages, including increased reproducibility and sensitivity to detect mild or diffuse disease. The role of multiparametric mapping MRI in characterizing various tissue types in pancreatic disease such as chronic pancreatitis (CP) and pancreatic ductal adenocarcinoma (PDAC) has rarely been evaluated.

Purpose

To evaluate the feasibility of multiparametric mapping [T1, T2, and apparent diffusion coefficient (ADC)] in defining tissue characteristics that occur in CP and PDAC to improve disease diagnosis.

Materials and Methods:

Pancreatic MRI was performed in 17 patients with PDAC undergoing therapy, 7 patients with CP, and 29 healthy volunteers with no pancreatic disease. T1 modified Look-Locker Inversion Recovery (T1 MOLLI), T2-prepared gradient-echo, and multi-slice single-shot echo-planar diffusion weighted imaging (SS-EPI DWI) sequences were used for data acquisition. Regions of interest (ROIs) of pancreas in PDAC, CP, and control subjects were outlined by an experienced radiologist. One-way analysis of variance (ANOVA) was used to compare the difference between groups and regions of the pancreas, and Tukey tests were used for multiple comparison testing within groups. Receiver operator characteristic (ROC) curves were analyzed, and the areas under the curves (AUCs) were calculated using single parameter and combined parameters, respectively.

Results

T1, T2, and ADC values of the entire pancreas among PDAC, CP, and control subjects; and between upstream and downstream portions of the pancreas in PDAC patients were all significantly different (p < 0.05). The AUC values were 0.90 for T1, 0.55 for T2, and 0.71 for ADC for independent prediction of PDAC. By combining T1, T2, and ADC, the AUC value was 0.94 (sensitivity 91.54%, specificity 85.81%, 95% CI: 0.92–0.96), which yielded higher accuracy than any one parameter only (p < 0.001).

Conclusion

Multiparametric mapping MRI is feasible for the evaluation of the differences between PDAC, CP, and normal pancreas tissues. The combination of multiple parameters of T1, T2, and ADC provides a higher accuracy than any single parameter alone in tissue characterization of the pancreas.

Six-dimensional quantitative DCE MR Multitasking of the entire abdomen: Method and application to pancreatic ductal adenocarcinoma

PURPOSE

To develop a quantitative DCE MRI technique enabling entire-abdomen coverage, free-breathing acquisition, 1-second temporal resolution, and T₁ -based quantification of contrast agent concentration and kinetic modeling for the characterization of pancreatic ductal adenocarcinoma (PDAC).

METHODS

Segmented FLASH readouts following saturation-recovery preparation with randomized 3D Cartesian undersampling was used for incoherent data acquisition. MR Multitasking was used to reconstruct 6-dimensional images with 3 spatial dimensions, 1 T₁ recovery dimension for dynamic T₁ quantification, 1 respiratory dimension to resolve respiratory motion, and 1 DCE time dimension to capture the contrast kinetics. Sixteen healthy subjects and 14 patients with pathologically confirmed PDAC were recruited for the in vivo studies, and kinetic parameters v_p , K^trans , v_e , and K_ep were evaluated for each subject. Intersession repeatability of Multitasking DCE was assessed in 8 repeat healthy subjects. One-way unbalanced analysis of variance was performed between control and patient groups.

RESULTS

In vivo studies demonstrated that v_p , K^trans , and K_ep of PDAC were significantly lower compared with nontumoral regions in the patient group (P = .002, .003, .004, respectively) and normal pancreas in the control group (P = .011, <.001, <.001, respectively), while v_e was significantly higher than nontumoral regions (P < .001) and healthy pancreas (P < .001). The kinetic parameters showed good in vivo repeatability (interclass correlation coefficient: v_p , 0.95; K^trans , 0.98; v_e , 0.96; K_ep , 0.99).

CONCLUSION

The proposed Multitasking DCE is promising for the quantification of vascular properties of PDAC. Quantitative DCE parameters were repeatable in vivo and showed significant differences between normal pancreas and both tumor and nontumoral regions in patients with PDAC.

Lumen-apposing stents versus plastic stents in the management of pancreatic pseudocysts: a large, comparative, international, multicenter study

BACKGROUND

Larger caliber lumen-apposing stents (LAMSs) have been increasingly used in the management of pancreatic fluid collections, specifically when solid debris is present; however, their advantages over smaller caliber plastic stents in the management of pancreatic pseudocysts are unclear. The aim of this study was to investigate the safety and efficacy of LAMS specifically in the management of pancreatic pseudocysts compared with double-pigtail plastic stents (DPPSs).

METHODS

We performed a multicenter, international, retrospective study between January 2012 and August 2016. A total of 205 patients with a diagnosis of pancreatic pseudocysts were included, 80 patients received LAMSs and 125 received DPPSs. Measured outcomes included clinical success, technical success, adverse events, stent dysfunction, pancreatic pseudocyst recurrence, and need for surgery.

RESULTS

Technical success was similar between the LAMS and the DPPS groups (97.5 % vs. 99.2 %; P = 0.32). Clinical success was higher for LAMSs than for DPPSs (96.3 % vs. 87.2 %; P = 0.03). While the need for surgery was similar between the two groups (1.3 % vs. 4.9 %, respectively; P = 0.17), the use of percutaneous drainage was significantly lower in the LAMS group (1.3 % vs. 8.8 %; P = 0.03). At 6-month follow-up, the recurrence rate was similar between the groups (6.7 % vs 18.8 %, respectively; P = 0.12). The rate of adverse events was significantly higher in the DPPS group (7.5 % vs. 17.6 %; P = 0.04). There was no difference in post-procedure mean length of hospital stay (6.3 days [standard deviation 27.9] vs. 3.7 days [5.7]; P = 0.31).

CONCLUSION

When compared to DPPSs, LAMSs are a safe, feasible, and effective modality for the treatment of pancreatic pseudocysts and are associated with a higher rate of clinical success, shorter procedure time, less need for percutaneous interventions, and a lower overall rate of adverse events.

Low Frequency of Lymph Node Metastases in Patients in the United States With Early-stage Gastric Cancers That Fulfill Japanese Endoscopic Resection Criteria

BACKGROUND & AIMS

In the West, early gastric cancer is increasingly managed with endoscopic resection (ER). This is, however, based on the assumption that the low prevalence and risk of lymph node metastases observed in Asian patients is applicable to patients in the United States. We sought to evaluate the frequency of and factors associated with metastasis of early gastric cancers to lymph nodes, and whether the Japanese ER criteria are applicable to patients in the US.

METHODS

We performed a retrospective study of 176 patients (mean age 68.5 years; 59.1% male; 58.5% white) who underwent surgical resection with lymph node dissection of T1 and Tis gastric adenocarcinomas, staged by pathologists, at 7 tertiary care centers in the US from January 1, 1999, through December 31, 2016. The frequency of lymph node metastases and associated risk factors were determined.

RESULTS

The mean size of gastric adenocarcinomas was 23.0 ± 16.6 mm-most were located in the lower-third of the stomach (67.0%), invading the submucosa (55.1%), and moderately differentiated (31.3%). Lymphovascular invasion was observed in 18.2% of lesions. Overall, 20.5% of patients had lymph node metastases. Submucosal invasion (odds ratio, 3.9; 95% CI, 1.4-10.7) and lymphovascular invasion (odds ratio, 4.6; 95% CI, 1.8-12.0) were independently associated with increased risk of metastasis to lymph nodes. The frequency of lymph node metastases among patients fulfilling standard and expanded Japanese criteria for ER were 0 and 7.5%, respectively.

CONCLUSIONS

The frequency of lymph node metastases among patients with early gastric cancer in a US population is higher than that of published Asian series. However, early gastric cancer lesions that meet the Japanese standard criteria for ER are associated with negligible risk of metastasis to lymph nodes, so ER can be recommended for definitive therapy. Expanded criteria cancers appear to have a higher risk of metastasis to lymph nodes, so ER may be considered for select cases.

Lower Annual Rate of Progression of Short-Segment vs Long-Segment Barrett's Esophagus to Esophageal Adenocarcinoma

BACKGROUND & AIMS

European guidelines recommend different surveillance intervals of non-dysplastic Barrett's esophagus (NDBE) based on segment length, as opposed to guidelines in the United States, which do recommend surveillance intervals based on BE length. We studied rates of progression of NDBE to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) in patients with short-segment BE using the definition of BE in the latest guidelines (length ≥1 cm).

METHODS

We collected demographic, clinical, endoscopy, and histopathology data from 1883 patients with endoscopic evidence of NDBE (mean age, 57.3 years; 83.5% male; 88.1% Caucasians) seen at 7 tertiary referral centers. Patients were followed for a median 6.4 years. Cases of dysplasia or EAC detected within 1 year of index endoscopy were considered prevalent and were excluded. Unadjusted rates of progression to HGD or EAC were compared between patients with short (≥1 and <3) and long (≥3) BE lengths using log-rank tests. A subgroup analysis was performed on patients with a documented Prague C&M classification. We used a multivariable proportional hazards model to evaluate the association between BE length and progression. Adjusted hazards ratios were calculated after adjusting for variables associated with progression.

RESULTS

We found 822 patients to have a short-segment BE (SSBE) and 1061 to have long segment BE (LSBE). We found patients with SSBE to have a significantly lower annual rate of progression to EAC (0.07%) than of patients with LSBE (0.25%) (P = .001). For the combined endpoint of HGD or EAC, annual progression rates were significantly lower among patients with SSBE (0.29%) compared to compared to LSBE (0.91%) (P < .001). This effect persisted in multivariable analysis (hazard ratio, 0.32; 95% CI, 0.18-0.57; P < .001).

CONCLUSION

We analyzed progression of BE (length ≥1 cm) to HGD or EAC in a large cohort of patients seen at multiple centers and followed for a median 6.4 years. We found a lower annual rate of progression of SSBE to EAC (0.07%/year) than of LSBE (0.25%/year). We propose lengthening current surveillance intervals for patients with SSBE.

Lumen apposing metal stents are superior to plastic stents in pancreatic walled-off necrosis: a large international multicenter study

Background and study aims  The use of lumen apposing metal stents (LAMS) during EUS-guided transmural drainage (EUS-TD) of pancreatic walled-off necrosis (WON) has gained popularity. Data supporting their use in WON over plastic stents (PS), however, remain scarce. The aim of this study was to compare the clinical efficacy of LAMS (Axios, Boston Scientific) with PS in WON. Patients and methods  This was a multicenter, retrospective study involving 14 centers. Consecutive patients who underwent EUS-TD of WON (2012 - 2016) were included. The primary end point was clinical success defined as WON size ≤ 3 cm within a 6-month period without need for percutaneous drainage (PCD) or surgery. Results  A total of 189 patients (mean age 55.2 ± 15.6 years, 34.9 % female) were included (102 LAMS and 87 PS). Technical success rates were similar: 100 % in LAMS and 98.9 % in PS ( P  = 0.28). Clinical success was attained in 80.4 % of LAMS and 57.5 % of PS ( P  = 0.001). Rate of PCD was similar (13.7 % LAMS vs. 16.3 % PS, P  = 0.62), while PS was associated with a greater need for surgery (16.1 % PS vs. 5.6 % LAMS, P  = 0.02). Adverse events (AEs) were observed in 9.8 % of LAMS and 10.3 % of PS ( P  = 0.90) and were rated as severe in 2.0 % and 6.9 %, respectively ( P  = 0.93). After excluding patients with < 6 months follow-up, the rate of WON recurrence following initial clinical success was greater with PS (22.9 % PS vs. 5.6 % LAMS, P  = 0.04). Conclusions  When compared to PS, LAMS in WON is associated with higher clinical success, shorter procedure time, lower need for surgery, and lower rate of recurrence.